Failure to Monitor and Manage Diabetes Leading to Hospitalization
Penalty
Summary
A resident with a history of Type 2 Diabetes Mellitus and vascular dementia was not provided with care that met professional standards, as routine laboratory testing to monitor diabetes control was not performed. The resident's last documented Hemoglobin A1c (HgA1c) test was over a year prior, despite facility policy and American Diabetes Association guidelines recommending regular testing. The resident's diabetes was diet-controlled, and the care plan required monitoring for signs and symptoms of hypo/hyperglycemia, but there was no documentation that such monitoring occurred. On a specific day, the resident experienced a significant change in condition, presenting as lethargic, refusing meals, and being unresponsive. Nursing staff, including two nurses assigned to the resident, did not recognize or act upon the resident's diabetes diagnosis during their assessments. One nurse stated she was unaware of the diabetes diagnosis, despite signing off on diabetic foot care in the treatment administration record. Another nurse, who was aware of the diagnosis, could not recall if a finger stick blood sugar was checked, and there was no documentation that this assessment was performed. The resident was eventually found to have a critically high blood glucose level (611 mg/dl) and elevated sodium, leading to transfer to the hospital and admission for hyperosmolar hyperglycemic state and hypernatremia. Interviews with facility staff, including the nurse practitioner and director of nursing, revealed a lack of awareness regarding the overdue HgA1c testing and uncertainty about whether staff were monitoring for diabetes-related complications as required by the care plan.